Refractory Osteomyelitis

Brett B. Hart, M.D.

Refractory osteomyelitis is chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where an acute osteomyelitis does not respond to accepted management techniques (1). Patients with refractory osteomyelitis frequently suffer from coexisting local and systemic factors that compromise their responsiveness to infection. Hyperbaric oxygen (HBO2), when combined with appropriate antibiotics, nutritional support, surgical debridement and reconstruction, provides a useful clinical adjunct in the management of refractory bone infections. Overall, the addition of HBO2 therapy to the clinical management of previously refractory osteomyelitis produces infection arrest rates in approximately 80% of cases.

Initial evidence for this therapeutic benefit stemmed from reports collected during the 1960s, in which difficult cases of osteomyelitis were successfully treated by the addition of HBO2 therapy (2-5). A series of controlled animal studies subsequently confirmed the perceived clinical benefit of HBO2 (6-9). More recently, in vitro and in vivo studies have revealed specific mechanisms of action that explain the benefits seen with HBO2 treatment of refractory osteomyelitis. Common to each mechanism is the generation of normal to elevated tissue oxygen tensions in infected bone. Mader and Niinikoski demonstrated that the decreased oxygen tensions typically associated with infected bone can be elevated to normal or above normal while breathing 100% oxygen in a hyperbaric chamber (10). Such elevations have important consequences for the hypoxic milieu of osteomyelitic tissues.1